Provider Demographics
NPI:1194026211
Name:BENNETT-SELBY, KIM (LCSW-C)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:
Last Name:BENNETT-SELBY
Suffix:
Gender:F
Credentials:LCSW-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1331 CHARLESTOWN DR
Mailing Address - Street 2:
Mailing Address - City:EDGEWOOD
Mailing Address - State:MD
Mailing Address - Zip Code:21040-2204
Mailing Address - Country:US
Mailing Address - Phone:443-928-9554
Mailing Address - Fax:
Practice Address - Street 1:1331 CHARLESTOWN DR
Practice Address - Street 2:
Practice Address - City:EDGEWOOD
Practice Address - State:MD
Practice Address - Zip Code:21040-2204
Practice Address - Country:US
Practice Address - Phone:443-928-9554
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-04
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD091841041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD052507300Medicaid